HomeMy WebLinkAbout1324A � WORKERS'COMPENSATIONDECLARATION epai ��er�nn� �C1R PFRMIT �
� hereby affirm that I hove n certifi<nte of conseN fo self ^• • "v�""'�'� • �'� ` `�'"^"
sure,or a certifimte of Workers'Compensafion i�5��a��e, HEATING - VENTILATING - AIR CONDITIONING
o certified capy��hereof(Gec 380Q Lab.C.) 76A36nC
� CF-818(REV.1 D/81)
� _,P�olicy No. Company �
Certifietl copy is hereby furnished. 'COUNTY OP LOS ANGELE5 BUILUING AND SAFETY
� � Certified copy is filed with ihe county b�ilding inspeo FOR APPLICANT TO FILL IN aui�oiNG � . ��� J' �
tion departmeni. ADDRE55 _ f
�PRINT OR TYPE ON�YI
� Date Appliarnt . tOCALITY ��
NO. TYPE OP APPLIANCE OR EQUIPMENi FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
� COMPENSATION INSURANCE CROSS Si.
� (This section need noT be compieTed H Tbe work involved by ABSORPTION UNIT,BTU oisteict No. PFocesseo ev
� ihe permit(s for one hundred dollars(SI00)or less.) ��
� I certify that in the periormance of ihe work for which this AIR HANotING UNIT,CFM
permit is issued,I shall nof employ any person in any manner
.� so as to become subjeci to the Workers'Compensation Laws. BOILER,BTU �� � nvPaovnis onre ��Ns aua�s si�NarueF
v//�� �`�"� �/� COMPRESSOR,BTU ROUGH
� �`Date_1�_—/�Applimni , _
NOTICE TO APPllCANT: If, affer making ihis Certifimte of vEN71tATION SVSTEM FINAL •�-
Exemption, you shauld become subject to ihe Workers'
� Compensation provisions of the�Labor Code,you must forfh- EVAPORATIVE COOIeK 1 V LIDATIOPF� ,�'���,r=-
with mmply with suth provisions or ihis permit shall be �{� �l,�j �C� ,�.�
� deemed revoked. FURNACE: Fnu cqnwTv � F -7
LICFNSED CONTRACTQRS DECLARATIDN FIOOR _BTU �-��`��, 3�� t r�L_���`F�
�� I hereby affirm fhat�am licensed under provisions nf Chapter 9 HEATER: SUSPENDED_ UNIT— ���r`.�.,`�..�-�
-{cor:m?ncing with Sec±ion 7000)�of Division 3 of the Business � WA�� ±�
-___.___
and Professions Code,and my license is in fuli torce and effect. 9,
� License Number Lic.Class �
� �
� Contrac�or Datc �
❑ °a.f
� i am exempt under Sec. �
Plcn check fee
B.&P.C.for this.eason PERMIT ISSUING FEE$ �'J .5� ''
� Date'
� Signotu�e TOTAI FEE U 1
� OWNER-BUILOER DECLARATION Ptan,'CHECK.4PPLICANT
I hereby affirm that I am exempt from the Coniractor s Licensa . �
� iaw for the following reason (Section 7031.5;8usiness and � NAME . .
Professions Code):
� laDDRE55"
� I, as owner of the property, or my empioyees with �
� `�wages as their sole cnmpensation,will do the work and _____a � ` ' g�'1'�� ,
the slruc}ure is not in?ended or offered for sale(Section CITY TEL NO. �T„_,,,o�,�
7044,Business and Professions Cade). - �`}� g � � ��:
� OWNER J
❑ I,os owner of the property,dm exclusively coN«�cting � t a s��-U�v
with ficensed contractors ro consir�ct the project(Seo � M��� . �
ADDRE55
yyy tion 7044,Business and Professions Code). � ���� " e � s,',^,L,��%�
� CONSTRUCTION LENDING AGENCY - GTY������ � TEL NQ �,�
I hereby affirm that tf-�ere is a mnstruction lending agency for �, (�Q�t r--'''�-;
ihe performance of the work for which this permii is issued CONTRhCTOR
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name ___ .
CITY TEL NO. -
Lender's Address
- STA1[ LIC.
I certify Iha?I hav=read this application qnd siafe fhat ihe IICENSE NO: CLASS � � � �
above information is corred.I ogree to comply with a�l County _
ordinances and State laws relating to building consh�ction,
{ and here 'ufhorize representatives of ihls County fo enfer
i upor�th ove-men on ro ry for inspedion purposes. SEE REVERSE FOR EXPLANATORY IANGUAGE
� � Signarure of Appllmnt or Agani Dote
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